BACKGROUND:Gallbladder cancer (GBC) is a lethal malignancy for which the substantial survival benefit of guideline-mandated R0 resection is fundamentally constrained by the advanced stage at which most patients present. The determinants of long-term survival and the optimal surgical approach, particularly for incidental GBC (IGBC), remain insufficiently defined. We aimed to address these gaps in a large, contemporary cohort. METHODS:We retrospectively analyzed 416 consecutive patients who underwent surgery for GBC at a national tertiary center (2003-2022). The primary endpoints of overall survival (OS) and disease-free survival (DFS) were assessed using Kaplan-Meier analysis and multivariable Cox regression. A prospectively registered systematic review and meta-analysis (PROSPERO: CRD42024501216) was performed to contextualize the role of surgical approach in IGBC. RESULTS:The cohort was characterized by a predominance of advanced-stage disease (68% stage III-IV), with an R0 resection rate of 44.0%. Perioperative morbidity was 12.7% and 30-day mortality was 0.7%. Compared to conventional GBC, IGBC was diagnosed at significantly earlier stages, resulting in a lower recurrence rate (20.0% vs. 34.7%, P = 0.044) and improved median OS (56.5 vs. 32.0 months). Multivariable analysis confirmed that survival was overwhelmingly dictated by adverse tumor biology (e.g., poor differentiation, nodal involvement, M1 status). R0 resection emerged as the sole, powerful, modifiable protective factor for both OS (HR 0.27) and DFS (HR 0.23). The meta-analysis demonstrated a significant, stage-dependent survival benefit for a primary laparoscopic approach in IGBC, particularly for T2 tumors. CONCLUSION:The prognosis of GBC is fundamentally determined by tumor biology at presentation. Within this paradigm of biological determinism, achieving an R0 resection is the most critical surgical intervention to improve survival. For appropriately selected patients with IGBC, a laparoscopic approach confers a survival advantage, reinforcing the dual importance of strategies that facilitate both earlier detection and guideline-adherent oncologic resection.
INTRODUCTION:The effects of frailty on postoperative complications, functional outcomes, and survival in very old patients undergoing soft tissue sarcoma (STS) surgery remain unclear. Therefore, this study aimed to determine the frequency of postoperative complications and ADL decline, the association of frailty and surgical invasiveness with outcomes, and whether complications or frailty-related factors influence hospital stay length and overall survival. MATERIALS AND METHODS:We retrospectively reviewed 120 patients aged ≥80 years who had undergone resection of localized malignant soft tissue tumors in the limbs or trunk at a single cancer center (2012-2024). Clavien-Dindo classification was used to evaluate their postoperative complications. Primary endpoints were the incidence of complications and the rate of functional decline. Secondary endpoints were length of hospital stay and overall survival. Logistic regression was used to identify factors associated with complications and postoperative care dependency, and the Kaplan-Meier method was used to analyze survival. RESULTS:Sixty-six patients developed grade ≥ II postoperative complications (both surgery- and nonsurgery-related) with no reported deaths. Multivariate analysis revealed that the Geriatric Nutritional Risk Index risk group and longer operation time were significant factors. Postoperative delirium was the strongest predictor of subsequent functional decline. Patients with complications had a 10.5-day longer hospital stay than those without complications. The 2-year overall survival rate was 74.3%. Postoperative complications did not significantly affect overall survival, whereas frailty was independently associated with poor overall survival. CONCLUSION:Malnutrition and cognitive vulnerability were identified as predictors of postoperative complications and loss of independence among very old patients with STS. Incorporating geriatric assessments and prehabilitation strategies may help mitigate these risks and improve outcomes.
As the global population ages, the number of older adults undergoing surgery for gastrointestinal cancer continues to increase. Although advances in surgical techniques have expanded treatment options for older patients with gastrointestinal cancer, age-related vulnerability and heterogeneity in functional reserve pose substantial challenges to surgical decision-making. Geriatric assessment (GA) is a multidimensional evaluation designed to identify vulnerabilities that are not captured by conventional surgical risk assessments. While GA has been widely recommended in medical oncology, its role in surgical oncology has not been comprehensively elucidated. We conducted a structured narrative review to clarify the applicability of GA and GA-guided management (GAM) in older surgical patients with gastrointestinal cancer. Existing studies suggest that GA may be useful for identifying previously unrecognized vulnerabilities, thereby supporting surgical and perioperative decision-making. Selected studies indicate potential benefits of GAM in reducing postoperative complications and geriatric syndromes. Further prospective studies focusing on patient-centered outcomes are warranted for broader implementation of GA and GAM.
OBJECTIVES:The management of non-small cell lung cancer (NSCLC) in elderly patients is an increasing clinical challenge. This study compared postoperative and oncologic outcomes between anatomical and wedge resections in patients aged ≥75 years. Primary endpoints were overall survival (OS) and disease-free survival (DFS). Secondary endpoints included predictors of postoperative complications and survival. METHODS:This retrospective study included 393 patients aged ≥75 years who underwent surgery for NSCLC between 2010 and 2019. Among them, 103 underwent wedge resection and 290 anatomical resection. Demographic, clinical, surgical, and oncologic data were collected. Multivariate analyses identified predictors of complications, OS, and DFS. RESULTS:Patients undergoing wedge resection were older and had higher comorbidity scores but experienced shorter operative times and fewer complications. Five-year OS and DFS were 53.2% and 56.8%, respectively, with no significant differences between groups. Reduced FEV1, open surgery, and longer operative time independently predicted postoperative complications. Male sex, higher comorbidity burden, smoking, reduced FEV1, and postoperative complications were associated with worse OS. CONCLUSIONS:Wedge resection represents a safe alternative to anatomical resection in selected elderly patients, with comparable survival outcomes and reduced perioperative burden. Careful preoperative selection remains essential.
Surgical resection is an important curative treatment for patients with bone and soft tissue sarcomas, often preceded by neoadjuvant therapy to reduce tumor size, enhance resectability and improve oncological outcomes. Fluorescence-guided surgery (FGS) has emerged as a promising technique to enhance intraoperative tumor visualization and resection precision. However, the impact of neoadjuvant therapy on the efficacy of FGS remains an area of ongoing investigation. This narrative review explores the current existing literature on the relationship between neoadjuvant therapies and the effectiveness of fluorescence-guided sarcoma surgery, identifying what has been learned from previous studies implementing FGS, and to hypothesize what is relevant for future studies.
BACKGROUND:Hepatocellular carcinima (HCC) is a common malignant tumor with poor prognosis, mainly because of high recurrence after surgery. The aim of this study was to evaluate the efficacy of neoadjuvant treatment, consisting of preoperative transarterial chemoembolization (TACE) with lenvatinib and programmed death 1(PD-1) inhibitors, in resectable HCC patients with China Liver Cancer Staging (CNLC) stage Ib to IIIa. METHODS:This retrospective multicenter study compared outcomes of patients who completed neoadjuvant treatment and surigical resection with hepatectomy alone. All Patients were 1:3 propensity score matched with each comparison. Neoadjuvant treatment included TACE with PD-1 inhibitors plus lenvatinib. RESULTS:A total of 401 patients were enrolled of whom 74 (18.5%) received neoadjuvant treatment. 62 (83.8%) of these patients had adverse events (AEs) and 2 (2.7%) patients had grade 3/4 of alanine aminotransferase (ALT) level elevated or leukocytopenia. All patients performed surgery successfully and no severe postoperative complications occurred. The objective response rate (ORR) was 55.4% and 81.1% based on RECIST 1.1 and mRECIST in neoadjuvant group. 25 (33.8%) patients had radiological complete tumor necrosis and the disease control rate (DCR) was 100%. The pathological complete response (pCR) and major pathological response (MPR) was 24 (32.4%) and 37 (50.0%), respectively. The incidence of microvascular invasion (MVI) was 28.4% in neoadjuvant treatment patients, compared with 50.9% for surgery alone patients. Neoadjuvant treatment patients had a significant better prognosis than surgery alone patients (progression-free survival p = 0.017, overall survival p = 0.017). CONCLUSIONS:Neoadjuvant TACE, lenvatinib and PD-1 inhibitors treatment is safe and beneficial to the pathological results and prognosis for patients with resectable HCC with CNLC stage Ib to IIIa.
BACKGROUND:Hepatocellular carcinoma (HCC) with cirrhotic hypersplenism creates a surgical dilemma because hepatectomy alone (HA) leaves cytopenia untreated, whereas hepatectomy plus splenectomy (HS) may increase operative and thrombotic risk. AIM:To compare HA, HS, and hepatectomy plus splenic arterial flow reduction (SAFR) in patients with HCC and cirrhotic hypersplenism undergoing curative-intent hepatectomy. METHODS:Six databases were searched to 31 March 2026. Comparative studies were pooled using pairwise meta-analysis and exploratory frequentist network meta-analysis. Risk of bias was assessed using ROBINS-I. RESULTS:Thirty studies involving 3967 patients were included. Eight-study primary analyses associated HS with longer overall survival (HR = 0.73, 95% CI 0.62-0.85) and recurrence-related survival (HR = 0.67, 95% CI 0.59-0.76) than HA, while HS was associated with more portal vein thrombosis (RR = 6.00, 95% CI 3.35-10.74) and major complications (RR = 1.57, 95% CI 1.10-2.23). In the exploratory network meta-analysis, both HS and SAFR were associated with greater postoperative platelet and white blood cell recovery than HA; evidence for SAFR was sparse and heterogeneity was substantial. CONCLUSION:HS was associated with longer survival and greater early hematological recovery than HA, but also with greater thrombotic and major-complication risks. SAFR was associated with improved early blood counts without a similar increase in thrombotic or complication risk, identifying it as a promising alternative to splenectomy. Although current evidence is limited, SAFR merits further prospective evaluation.
INTRODUCTION:We evaluated whether computed tomography (CT)-based body composition parameters predict outcomes after hyperthermic intraperitoneal chemotherapy (CRS ± HIPEC) for gastric peritoneal metastases (GPM). METHODS:A retrospective analysis of a prospectively maintained single-centre database included consecutive patients undergoing CRS ± HIPEC for GPM between January 2014 and December 2024. Skeletal muscle index (SMI), muscle radiodensity, and adipose tissue parameters were quantified on preoperative CT at the third lumbar vertebra. Sarcopenia was defined using validated sex-specific cut-offs. Postoperative complications, progression-free survival (PFS), and overall survival (OS) were analysed using multivariable regression and sensitivity analyses based on alternative sarcopenia definitions. RESULTS:Among 108 procedures performed in 106 included patients, 36 (33%) were sarcopenic. Major complications did not differ significantly (44% vs 39%; OR 1.26, 95% CI 0.56-2.83; p = 0.679), although moderate differences could not be excluded. In the overall cohort, neither PFS nor OS differed significantly according to sarcopenia status. However, among patients with synchronous GPM, sarcopenia was associated with shorter OS (median 10.2 vs 16.3 months; HR 1.85, 95% CI 1.05-3.25; p = 0.033), with a consistent but non-significant multivariable trend (p = 0.061). An adjusted interaction analysis supported effect modification according to disease timing (p for interaction = 0.043). Sensitivity analyses using four alternative sarcopenia definitions yielded consistent findings. CONCLUSION:Preoperative CT-defined sarcopenia identifies patients with synchronous GPM at higher risk of poor overall survival after CRS ± HIPEC without a detectable increase in postoperative morbidity. CT-based body composition may improve preoperative prognostic stratification and help identify candidates for future studies of nutritional optimisation or multimodal prehabilitation.
BACKGROUND:The prognostic significance of the interval between initial cancer diagnosis and development of femoral metastasis requiring surgery remains unclear. This study evaluated the association between this interval and overall survival in patients undergoing surgery for metastatic femoral lesions. METHODS:A retrospective cohort study was conducted among 314 patients treated surgically for metastatic femoral disease at a single center between 2005 and 2019. The primary exposure was the interval between cancer diagnosis and surgery for femoral metastasis: <1 year, 1-5 years, and >5 years. Data included demographics, tumor type, fracture status (actual versus impending), surgical modality, and Karnofsky performance score. Survival was assessed using Kaplan-Meier analysis, log-rank testing, and multivariable Cox regression adjusting for clinical and demographic variables. RESULTS:Median overall survival was 10 months (IQR 3-28). Survival differed significantly among diagnostic-interval groups (p < 0.001), with median survivals of 14 months in the <1-year group, 7 months in the 1-5-year group, and 14 months in the >5-year group. In multivariable analysis, a 1-5-year interval was associated with higher mortality compared with <1 year (HR = 1.79, 95% CI 1.31-2.43). Lower Karnofsky performance status and actual versus impending fracture were also independently associated with increased mortality. CONCLUSIONS:The interval between cancer diagnosis and surgery for femoral metastasis is independently associated with overall survival. Incorporating this readily available clinical variable may serve as a complementary factor in preoperative survival assessment and assist in patient counseling and surgical planning.
INTRODUCTION:The diagnostic role of nodal staging is well-established for defining risk classes and tailoring adjuvant treatment. When lymph node metastasis is identified, it significantly impacts survival. Due to the paucity of available data, it remains unclear if there is still a role for systematic lymphadenectomy in offering a therapeutic benefit. METHODS:This retrospective observational study included patients with FIGO stage IIIC endometrial cancer treated between 2008 and 2020. Patients were divided into two cohorts according to the number of harvested lymph nodes (<22 vs ≥ 22) and into three cohorts according to the number of metastatic lymph nodes (0-2, 3-9 and ≥10 positive lymph nodes). The main outcome measures were disease-free survival and overall survival. RESULTS:A total of 221 patients were analyzed. The number of harvested lymph nodes did not impact survival. Conversely, the number of metastatic lymph nodes significantly affected survival: 5-year Disease Free Survival decreased from 64.8% (0-2 positive lymph nodes) to 36.8% (≥10 positive lymph nodes) (p = 0.004), and 5-year Overall Survival decreased from 83.8% to 51.9% (p = 0.002). High grade hystotype and the use of chemotherapy alone without radiation were independently associated with an increased risk of recurrence. Although the number of metastatic lymph nodes was associated with recurrence and survival in the univariable analysis, it was not an independent predictor in the multivariable model. CONCLUSION:Tumor characteristics and adjuvant treatment are the most important independent prognostic factors in stage IIIC endometrial cancer, beyond the extent of lymphadenectomy and the number of metastatic lymph nodes.
D2 lymphadenectomy remains the accepted oncological standard for resectable gastric cancer (GC). However, the increasing integration of perioperative immunotherapy and emerging insights into tumour-draining lymph node (TDLN) immunobiology raise questions regarding whether a uniformly anatomical approach to nodal dissection will remain biologically optimal across all treatment contexts. While lymphadenectomy provides essential locoregional control and pathological staging, TDLN may also function as immunologically active structures involved in antigen presentation, T-cell priming, and systemic antitumour immunity. Current evidence does not support de-escalation of D2 lymphadenectomy, given persistent uncertainty regarding residual nodal disease and the limitations of available response-assessment tools. Nevertheless, future lymphadenectomy strategies may evolve toward greater biological contextualisation integrating tumour biology, immune function, treatment response, and molecular heterogeneity. Whether surgical radicality should ultimately undergo comparable biological refinement remains an increasingly relevant question.
OBJECTIVE:Cancer antigen 125 (CA125) has been proposed as a prognostic biomarker in endometrial cancer; however, its role in routine postoperative surveillance remains controversial. This study aimed to evaluate the clinical utility of serial CA125 measurements for detecting endometrial cancer recurrence and to identify a prognostically relevant cutoff value. METHODS:We conducted a retrospective observational cohort study of patients with endometrial cancer treated at a single ESGO-accredited institution. Serial CA125 levels were measured at regular intervals during postoperative surveillance. An optimal CA125 cutoff value was derived using receiver operating characteristic analysis based on CA125 levels measured at a predefined 18-month postoperative landmark in patients alive and recurrence-free at that time. Recurrence-free survival was subsequently analyzed using Kaplan-Meier methods. RESULTS:Patients with recurrence showed progressively higher CA125 levels than disease-free patients, with statistically significant differences emerging at 15 months (p-value = 0.014) and 18 months (p-value = 0.005) after surgery. A CA125 cutoff of 9.58 U/mL at 18 months best predicted recurrence. Based on this value, 105 patients were classified as low-risk and 49 as high-risk. ROC curve analysis demonstrated good discriminatory ability (AUC = 0.72, p-value < 0.001). Kaplan-Meier analysis showed significantly worse recurrence-free survival in patients with CA125 ≥ 9.58 U/mL compared to those with lower values (p-value = 0.02). CONCLUSION:Selective serial monitoring of CA125 during postoperative surveillance may help identify patients at increased risk of endometrial cancer recurrence and serve as an adjunct to imaging and guideline-based risk stratification, pending prospective validation.
INTRODUCTION:Laparoscopic total gastrectomy (LTG) is increasingly used for gastric cancer, but its safety during implementation in Western practice remains debated, particularly regarding esophagojejunal leakage. This study compared short-term outcomes of LTG and open total gastrectomy (OTG) in a European cohort using propensity score matching. MATERIALS AND METHODS:This single-centre retrospective cohort included 198 consecutive patients who underwent curative-intent total gastrectomy with D2 lymphadenectomy for gastric adenocarcinoma between 2022 and 2025 (LTG, n = 112; OTG, n = 86). Propensity score matching based on age, sex, BMI, ASA class, neoadjuvant chemotherapy and clinical stage yielded 71 matched pairs. The primary endpoint was 30-day major morbidity (Clavien-Dindo ≥ IIIa). RESULTS:After matching, no statistically significant differences were observed in overall morbidity, major morbidity, 90-day mortality, or readmission. However, 90-day mortality was numerically higher after LTG (7.0% vs 1.4%), and esophagojejunal leakage was significantly more frequent after LTG (15.5% vs 4.2%, p = 0.046).Key surrogate oncological outcomes, including lymph node yield and R0 resection rate, were comparable. CONCLUSION:In this propensity score-matched European implementation cohort, LTG was associated with similar overall and major morbidity but a significantly higher esophagojejunal leakage rate and numerically higher 90-day mortality compared with OTG. Although surrogate pathological outcomes were comparable, these findings do not establish clinical equivalence between the two approaches and indicate that LTG implementation should remain cautious, structured, and subject to close monitoring of anastomotic safety.
BACKGROUND:Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) is the gold standard treatment for appendiceal adenocarcinomas (AA) with peritoneal dissemination. The prognostic relevance of lymph node positivity (LNP) and the role of right hemicolectomy (RHC) remain controversial. The aim was to determine the rate of LNP in AA according to histopathological grade and evaluate its impact on survival. METHODS:A retrospective analysis including all patients with mucinous and intestinal-type AA treated with CRS + HIPEC with curative intent at a UK national peritoneal tumour centre (2005-2024) was performed. A logistic regression assessed the factors associated with LNP. Survival outcomes were analysed using Kaplan-Meier methods and Cox regression. RESULTS:A total of 205 patients were included, of whom 60% underwent RHC. The overall LNP rate was 18% and varied by tumour grading, occurring in 1.2% of well-differentiated mucinous adenocarcinomas (MAC), compared with 34% of moderately-to-poorly differentiated MAC, 33% of signet-ring cell tumours, and 23% of intestinal-type adenocarcinomas (p < 0.001). Histological subtype was the sole independent predictor of LNP. Median follow-up was 61 months, with a 5-year OS of 73%. Neither LNP nor RHC independently influenced overall survival, peritoneal and systemic disease free survival. (pDFS and sDFS). Outcomes were driven by completeness of cytoreduction and grade of peritoneal metastases. CONCLUSIONS:LNP varies with primary AA pathology. This study has identified a cohort of well-differentiated MAC in whom the risk of lymph node metastases is low, suggesting a role for selective RHC as part of CRS + HIPEC. Both pDFS and sDFS were driven by high-grade peritoneal disease.
Despite widespread use, comparative outcomes across soft tissue reconstruction techniques for musculoskeletal tumor resection remain poorly characterized. A PRISMA-guided systematic review searched PubMed, Embase, Web of Science, Scopus, Cochrane Library, and Ovid MEDLINE from database inception through 30 June 2026. Ninety eligible studies were identified, evaluating gastrocnemius flap, free tissue transfer, local flap, and orthoplastic reconstruction. Reported limb-salvage rates exceeded 90% across all four reconstruction categories; gastrocnemius flap survival reached 94-100% and free flap survival 92-96%. Orthoplastic multidisciplinary planning was associated with lower wound complication rates. Technique selection should be individualized according to defect characteristics, radiation exposure, and institutional surgical expertise.
BACKGROUND:Pancreatic ductal adenocarcinoma (PDAC) is among the most aggressive malignancies, and peritoneal metastases (PM) represent the second most common site of dissemination, carrying a particularly poor prognosis. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is an emerging locoregional approach for intraperitoneal drug delivery. However, its role in PDAC-related PM remains poorly defined. METHODS:This retrospective, multicentric study based on the ISSPP registry included patients with PM from PDAC treated with PIPAC from the International Society for the Study of Pleura and Peritoneum (ISSPP) registry. Outcome measures were safety, reason for stopping PIPAC, overall survival (OS), treatment response and prognostic factors for suvival at the time of the first PIPAC. RESULTS:One hundred fifty six patients were treated with 350 PIPAC procedures in 6 centers. Three or more PIPAC were completed in 55 (35.2%) patients. No major surgical complications (Clavien-Dindo ≥3) occurred; grade 3-4 adverse events (CTCAE v5.0) were recorded in 10 of 350 procedures (2.9%), and 30-day mortality was 3.8% per patient (6/156), in all cases due to disease progression. The main reason for discontinuation were disease progression and poor general conditions in 77 (49.35%) and 10 (6.41%) patients respectively. Median OS was 19 months from diagnosis and 9 months from PIPAC1. Survival analysis from PM diagnosis based on intraperitoneal drug choice showed a median OS of 15 months in patients with cisplatin and doxorubicin and 23 months with nab-paclitaxel (p = 0.027). Multivariable ananlysis showed that an higher Peritoneal Cancer Index (PCI) at PIPAC1 (p = 0.008) was associated with worse survival, whereas the use of intraperitoneal nabpaclitaxel (p = 0.004). After a 120 days landmark analysis accounting for immortal-time bias, completion of ≥3 PIPAC procedures remained independently associated with survival (adjusted p = 0.005) CONCLUSION: PIPAC appears to be a safe treatment option for patients with PM from PDAC, with a low rate of major complications, however its feasibility is limited, as only about one third completed ≥3 procedures. In this multicentric cohort a hypothesis generating survival signal and histological response were observed, particularly with nab-paclitaxel-based regimens. Prospective studies are needed to validate PIPAC for palliative treatment of PM of pancreatic origin.
